Provider Demographics
NPI:1750592200
Name:MANTENUTO, STACEY ANNE (PT, MSPT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANNE
Last Name:MANTENUTO
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CAROLINA LN
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-1446
Mailing Address - Country:US
Mailing Address - Phone:978-692-2871
Mailing Address - Fax:
Practice Address - Street 1:170 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1643
Practice Address - Country:US
Practice Address - Phone:781-306-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist